You are on page 1of 3

Form 1042-S Foreign Person’s U.S.

Source Income Subject to Withholding


▶ Go to www.irs.gov/Form1042S for instructions and the latest information.
2022 OMB No. 1545-0096

Copy B
Department of the Treasury
Internal Revenue Service 0 0 0 2 6 5 0 3 9 7 UNIQUE FORM IDENTIFIER AMENDED AMENDMENT NO. for Recipient
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4” 3 13e Recipient’s U.S. TIN, if any 13f Ch. 3 status code 16
code
3a Exemption code 00 4a Exemption code 16 13g Ch. 4 status code
12 5 3b Tax rate 30 . 00 4b Tax rate 00 . 00 13h Recipient’s GIIN 13i Recipient’s foreign tax identification 13j LOB code
number, if any
5 Withholding allowance
6 Net income
7a Federal tax withheld 2 13k Recipient’s account number

7b Check if federal tax withheld was not deposited with the IRS because 228680961030101
escrow procedures were applied (see instructions) . . . . . . 13l Recipient’s date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . . .

8 Tax withheld by other agents 14a Primary Withholding Agent’s Name (if applicable)
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( ) 14b Primary Withholding Agent’s EIN
15 Check if pro-rata basis reporting
10 Total withholding credit (combine boxes 7a, 8, and 9)
2 15a Intermediary or flow-through entity’s EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
0 15d Intermediary or flow-through entity’s name
12a Withholding agent’s EIN 12b Ch. 3 status code 12c Ch. 4 status code
822182297 15 15e Intermediary or flow-through entity’s GIIN
12d Withholding agent’s name 15f Country code 15g Foreign tax identification number, if any
XXVI HOLDINGS INC.
12e Withholding agent’s Global Intermediary Identification Number (GIIN) 15h Address (number and street)

12f Country code 12g Foreign tax identification number, if any 15i City or town, state or province, country, ZIP or foreign postal code
US
12h Address (number and street) 16a Payer’s name 16b Payer’s TIN
1600 AMPHITHEATRE PARKWAY
12i City or town, state or province, country, ZIP or foreign postal code 16c Payer’s GIIN 16d Ch. 3 status code 16e Ch. 4 status code
MOUNTAIN VIEW, CA 94043
13a Recipient’s name 13b Recipient’s country code 17a State income tax withheld 17b Payer’s state tax no. 17c Name of state
RAJARATA SAHODARA HAULA LK
13c Address (number and street)
139/A. SALIYAPURA ANURADAPURA
13d City or town, state or province, country, ZIP or foreign postal code
ANURADHAPURA 50008
(keep for your records) Form 1042-S (2022)
Form 1042-S Foreign Person’s U.S. Source Income Subject to Withholding
▶ Go to www.irs.gov/Form1042S for instructions and the latest information.
2022 for Recipient
OMB No. 1545-0096

Copy C
Department of the Treasury
Internal Revenue Service 0 0 0 2 6 5 0 3 9 7 UNIQUE FORM IDENTIFIER AMENDED AMENDMENT NO. Attach to any Federal tax return you file
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4” 3 13e Recipient’s U.S. TIN, if any 13f Ch. 3 status code 16
code
3a Exemption code 00 4a Exemption code 16 13g Ch. 4 status code
12 5 3b Tax rate 30 . 00 4b Tax rate 00 . 00 13h Recipient’s GIIN 13i Recipient’s foreign tax identification 13j LOB code
number, if any
5 Withholding allowance
6 Net income
7a Federal tax withheld 2 13k Recipient’s account number

7b Check if federal tax withheld was not deposited with the IRS because 228680961030101
escrow procedures were applied (see instructions) . . . . . . 13l Recipient’s date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . . .

8 Tax withheld by other agents 14a Primary Withholding Agent’s Name (if applicable)
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( ) 14b Primary Withholding Agent’s EIN
15 Check if pro-rata basis reporting
10 Total withholding credit (combine boxes 7a, 8, and 9)
2 15a Intermediary or flow-through entity’s EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
0 15d Intermediary or flow-through entity’s name
12a Withholding agent’s EIN 12b Ch. 3 status code 12c Ch. 4 status code
822182297 15 15e Intermediary or flow-through entity’s GIIN
12d Withholding agent’s name 15f Country code 15g Foreign tax identification number, if any
XXVI HOLDINGS INC.
12e Withholding agent’s Global Intermediary Identification Number (GIIN) 15h Address (number and street)

12f Country code 12g Foreign tax identification number, if any 15i City or town, state or province, country, ZIP or foreign postal code
US
12h Address (number and street) 16a Payer’s name 16b Payer’s TIN
1600 AMPHITHEATRE PARKWAY
12i City or town, state or province, country, ZIP or foreign postal code 16c Payer’s GIIN 16d Ch. 3 status code 16e Ch. 4 status code
MOUNTAIN VIEW, CA 94043
13a Recipient’s name 13b Recipient’s country code 17a State income tax withheld 17b Payer’s state tax no. 17c Name of state
RAJARATA SAHODARA HAULA LK
13c Address (number and street)
139/A. SALIYAPURA ANURADAPURA
13d City or town, state or province, country, ZIP or foreign postal code
ANURADHAPURA 50008
Form 1042-S (2022)
Form 1042-S Foreign Person’s U.S. Source Income Subject to Withholding
▶ Go to www.irs.gov/Form1042S for instructions and the latest information.
2022 OMB No. 1545-0096

Copy D
for Recipient
Department of the Treasury
Internal Revenue Service 0 0 0 2 6 5 0 3 9 7 UNIQUE FORM IDENTIFIER AMENDED AMENDMENT NO. Attach to any state tax return you file
1 Income 2 Gross income 3 Chapter indicator. Enter “3” or “4” 3 13e Recipient’s U.S. TIN, if any 13f Ch. 3 status code 16
code
3a Exemption code 00 4a Exemption code 16 13g Ch. 4 status code
12 5 3b Tax rate 30 . 00 4b Tax rate 00 . 00 13h Recipient’s GIIN 13i Recipient’s foreign tax identification 13j LOB code
number, if any
5 Withholding allowance
6 Net income
7a Federal tax withheld 2 13k Recipient’s account number

7b Check if federal tax withheld was not deposited with the IRS because 228680961030101
escrow procedures were applied (see instructions) . . . . . . 13l Recipient’s date of birth (YYYYMMDD)
7c Check if withholding occurred in subsequent year with respect to a
partnership interest . . . . . . . . . . . . . .

8 Tax withheld by other agents 14a Primary Withholding Agent’s Name (if applicable)
9 Overwithheld tax repaid to recipient pursuant to adjustment procedures (see instructions)
( ) 14b Primary Withholding Agent’s EIN
15 Check if pro-rata basis reporting
10 Total withholding credit (combine boxes 7a, 8, and 9)
2 15a Intermediary or flow-through entity’s EIN, if any 15b Ch. 3 status code 15c Ch. 4 status code
11 Tax paid by withholding agent (amounts not withheld) (see instructions)
0 15d Intermediary or flow-through entity’s name
12a Withholding agent’s EIN 12b Ch. 3 status code 12c Ch. 4 status code
822182297 15 15e Intermediary or flow-through entity’s GIIN
12d Withholding agent’s name 15f Country code 15g Foreign tax identification number, if any
XXVI HOLDINGS INC.
12e Withholding agent’s Global Intermediary Identification Number (GIIN) 15h Address (number and street)

12f Country code 12g Foreign tax identification number, if any 15i City or town, state or province, country, ZIP or foreign postal code
US
12h Address (number and street) 16a Payer’s name 16b Payer’s TIN
1600 AMPHITHEATRE PARKWAY
12i City or town, state or province, country, ZIP or foreign postal code 16c Payer’s GIIN 16d Ch. 3 status code 16e Ch. 4 status code
MOUNTAIN VIEW, CA 94043
13a Recipient’s name 13b Recipient’s country code 17a State income tax withheld 17b Payer’s state tax no. 17c Name of state
RAJARATA SAHODARA HAULA LK
13c Address (number and street)
139/A. SALIYAPURA ANURADAPURA
13d City or town, state or province, country, ZIP or foreign postal code
ANURADHAPURA 50008
Form 1042-S (2022)

You might also like